Vitamin D and calcium in the human breast milk

doi:10.1016/j.beem.2018.01.007

Best Practice & Research Clinical Endocrinology & Metabolism

Volume 32, Issue 1, January 2018, Pages 39-45

https://doi.org/10.1016/j.beem.2018.01.007 Get rights and content

Vitamin D and calcium in the human milk is essential for the growth and the prevention of rickets in infants. In this review, we will discuss the physiology and the functions of vitamin D and calcium and the mechanisms of vitamin D and calcium transfer into the human breast milk. This review describes the recommended intake of vitamin D and calcium for infants and lactating mothers and the factors influencing the content of vitamin D and calcium in human milk. Furthermore, the measurement of vitamin D compounds and calcium in human breast milk is described in this review.

Introduction

Vitamin D and calcium play an important role in the prevention of rickets in infants. However, human breast milk contains little vitamin D (approximately 20 IU per liter), and women who are vitamin D–deficient provide even less to their breastfed infants [1], [2], ∗[3]. There are increasing reports of vitamin D deficiency among breast-fed infants who lack adequate sunlight exposure and do not receive vitamin D supplementation ∗[3], [4], [5], [6]. The milk of healthy lactating women contains relatively small amounts of vitamin D and 25-hydroxyvitamin D (25(OH)D). Therefore, exclusively breast-fed infants are more prone to vitamin D deficiency if sunlight exposure is limited [7]. According to the reports of nutritional rickets among US children published between 1986 and 2003, approximately 83% of children with rickets were described as African American or black, and 96% were breast-fed. Among children who were breast-fed, only 5% of records indicated vitamin D supplementation during breast-feeding [6]. Vitamin D deficiency among children is common in Australia, the Middle East, India, Africa, and South America [4], ∗[8]. Pregnant and lactating women who take a prenatal vitamin and a calcium supplement with vitamin D remain at high risk for vitamin D deficiency.

In this review, we will discuss the physiology and the functions of vitamin D and calcium, the mechanisms of vitamin D and calcium transfer into the human breast milk, recommended intake of vitamin D and calcium for infants and lactating mothers, Factors influencing the content of vitamin D and calcium in human breast milk, and the analytical methods to measure vitamin D and calcium in human breast milk.

Section snippets

Vitamin D and calcium physiology

Vitamin D is a group of fat-soluble secosteroids responsible for calcium homeostasis and bone metabolism. Major compounds of vitamin D are vitamin D3 made by animals including humans (cholecalciferol) and vitamin D2 made by plants (ergocalciferol). Vitamin D is synthesized in the skin from a derivative of cholesterol through the exposure to solar ultraviolet B (UVB) radiation in the spectrum of 280–320 nm, which comprises about 90% of vitamin D in the body in unsupplemented individuals. During

Vitamin D and calcium functions

Vitamin D plays a key role in maintaining bone health via the regulation of calcium and phosphorus absorption. Vitamin D deficiency leads to decrease of intestinal calcium absorption (hypocalcemia), which, in turn, increases the secretion of parathyroid hormone (PTH) (secondary hyperparathyroidism) [13]. PTH stimulates the kidneys to metabolize 25(OH)D into 1,25(OH)2D which aggravates the vitamin D deficiency. At the same time, PTH increases the excretion of phosphorous into urine. Thus,

Mechanisms of vitamin D and calcium transfer into human breast milk

Very little 25(OH)D passes from the maternal circulation to breast milk [17]. Instead, the neonate receives vitamin D in its parent form of Vitamin D3 in breast milk. Vitamin D content in the breast milk correlates with the serum levels of vitamin D in the mother. However, the vitamin D3 is quickly converted to 25(OH)D which leaves less vitamin D3 to transfer to the infants. This finding suggests the need for daily dosing of vitamin D to achieve breast milk transfer. The vitamin D concentration

Recommended intake of vitamin D and calcium for infants and lactating mothers

The adequate intake of vitamin D in infants up to 12 months is 400 IU (10 μg) with sensible sun exposure [3]. Infants require up to 30 min of sunlight per week wearing only a diaper and 2 h per week fully clothed with no hat [6]. The daily requirement recommended by the Endocrine Practice Guidelines Committee for this age group is 400–1000 IU with the tolerable upper intake level of 2000 IU [25]. The current recommendations of the Americans Academy of Pediatrics is that all breastfed infants be

Factors influencing the content of vitamin D and calcium in human breast milk

The amount of vitamin D and calcium transferred from mother to the infant through human breast milk varies dependent on the genetic factors, sociocultural factors, or dietary conditions of feeding mothers.

In a study which tested vitamin D levels in human breast milk from black women vs. white women, the total ARA was significantly higher in white lactating women than in black lactating women [27]. This difference can be attributed to the lower vitamin D intake and less sun exposure among black

Analytical methods to measure vitamin D and calcium in human breast milk

Vitamin D and 25(OH)D are the most important antirachitic sterols in human breast milk. Since milk is rich in triglycerides, free fatty acids, phospholipids, and many other lipophilic substances beside the antirachitic sterols, several steps of the sample pre-treatment have been required. Previously, the measurements of vitamin D in human breast milk were based on the use of HPLC with ultraviolet detection [38], competitive protein binding assay (CPBA) [39], radioimmunoassay [40], and enzyme

Summary

Vitamin D and calcium in human breast milk is dependent on the maternal vitamin D and calcium status in plasma and bone. Vitamin D status of breastfeeding mothers and infants should be assessed not only in genetic factor but also in life-style perspectives, since more various ethnic groups are co-existing than before and modern life style limits the sun exposure. Bone adaptation in lactating mothers to provide calcium in milk needs to be further investigated for the risk of osteoporosis in

Conflicts of interest

None.

Role of the funding source

None.

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La prise en charge diététique des enfants suivis pour allergie aux protéines de lait de vache (APLV) doit aller au-delà de la prescription d’un lait infantile de substitution et de conseils d’éviction. Ces patients sont exposés à un risque de carence calcique, par défaut d’apports en produits laitiers qui représentent la principale source d’apports en calcium chez les sujets sains. Jusqu’à 6 mois, la consommation des préparations sans PLV (hydrolysat poussé de protéines du lait de vache (HPPLV), hydrolysat de riz (HR) ou formule d’acides aminés (FAA)) permet d’assurer les besoins d’environ 200 mg/j de calcium. À partir de l’âge de la diversification alimentaire, il convient de maintenir une consommation journalière d’au moins 400 ml de ces préparations pour assurer les besoins en calcium (mais 700 ml sont nécessaires pour assurer la totalité des besoins en fer et en acides gras essentiels) ; l’ajout de mesures de poudre d’HPPLV, HR ou FAA dans les purées et compotes peut s’avérer nécessaire si l’enfant ne boit pas une quantité appropriée de biberons. L’ajout de desserts sans PLV spécifiques ou à base de boissons végétales enrichies en calcium permettra d’atteindre les apports calciques recommandés. À partir de 2–3 ans, lorsque la prise des HPPLV, HR ou FAA est plus limitée, ces desserts ou jus végétaux doivent être régulièrement proposés afin de couvrir les besoins calciques de 450 mg/j. Chez les enfants plus âgés, l’hydratation avec une eau riche en calcium et la supplémentation pharmaceutique en calcium sont d’autres mesures parfois utiles.
Physicians have to pay attention to the dietary management of the children with a cow's milk proteins allergy (CMPA), beyond the avoiding rules and the prescription of a specific formula. Risk of a lack of calcium intake is higher for these patients who do not consume cow's milk, usually the main source of calcium. It's important to easily assess calcium intake during the consultation and to advice caregivers to prevent this deficient risk. Up to the age of 6 months, child is fed with formulas adapted without cow's milk protein (an extensively hydrolyzed formula (EHF), an amino acid-based formula (AAF) or a hydrolyzed rice protein formulas (HRPF)), that ensure an adequate intake of average 200 mg of calcium per day. With food diversification, child has to daily drink over 400 ml (optimally 700 ml) of these formulas; few power spoons of EHF, AAF or HRPF could be added to puree and compotes. To obtain daily recommended diet, specific desserts without milk (available in pharmacy) or with plant based diet products may be helpful (available in supermarket). After 2 or 3 years old, EHF, AAF or HRPF are less consumed (tasteless and lassitude) and these desserts are an attractive alternative to ensure an intake of 450 mg of calcium per day. For elder patients with CMPA, other dietary options as calcium rich waters and calcium supplementation with tablets could be useful.
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We present here 35 clinical practice points (CPPs) for the use of native vitamin D therapy (ergocalciferol, vitamin D₂ and cholecalciferol, vitamin D₃) and calcium nutritional intakes in general pediatric populations.
This consensus document was developed to provide guidance to health care professionals on the use of nutritional vitamin D and dietary modalities to achieve the recommended calcium intakes in general pediatric populations. These CPPs will be revised periodically. Research recommendations to study key vitamin D outcome measures in children are also suggested.
Effect of heat treatment on micronutrients, fatty acids and some bioactive components of milk
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Milk is a nutrient-rich food with various micronutrients and bioactive components that are affected by heat treatment depending on time-temperature norm. Pasteurisation and short time ultra high temperature treatments do not cause significant changes in most micronutrients; however, intensive heat treatments such as in-bottle sterilisation can cause severe degradation of water-soluble vitamins, essential fatty acids and hormones. Exposure of heat-treated milk to light and oxygen has a more destructive effect on oxygen-sensitive micronutrients, unsaturated fatty acids and most vitamins than heat treatment itself. Therefore, losses during evaporation and drying processes can be significant and should be considered in evaluating the nutritional value of milk. Moreover, packaging material, storage temperature and duration also contribute to the losses. Application of severe heat may also cause minor losses in minerals due to precipitation in processing lines. An integral approach is recommended for retention of the nutritional value of raw milk in processed milk products.
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4Vitamin D and calcium in the human breast milk

Introduction

Section snippets

Vitamin D and calcium physiology

Vitamin D and calcium functions

Mechanisms of vitamin D and calcium transfer into human breast milk

Recommended intake of vitamin D and calcium for infants and lactating mothers

Factors influencing the content of vitamin D and calcium in human breast milk

Analytical methods to measure vitamin D and calcium in human breast milk

Summary

Conflicts of interest

Role of the funding source

Am J Clin Nutr

Am J Clin Nutr

J Pediatr

Am J Clin Nutr

Am J Clin Nutr

Endocrinol Metab Clin N Am

Lancet (London, England)

J Pediatr

J Pediatr

Am J Clin Nutr

J Nutr

Adv Nutr (Bethesda, Md.)

Best Pract Res Clin Endocrinol Metab

Endocrinol Metab Clin N Am

J Pediatr

J Dairy Sci

Am J Clin Nutr

J Pediatr

Anal Biochem

J Chromatogr B Anal Technol Biomed Life Sci

Am J Clin Nutr

Resurrection of vitamin D deficiency and rickets

J Clin Investig

Nutritional rickets around the world. Causes and future directions

Ann Trop Paediatr

Vitamin D deficiency

N Engl J Med

4
Vitamin D and calcium in the human breast milk